Download Treatment of Stress Incontinence

Evaluation and Treatment
of Urinary Incontinence
and Prolapse
Division of Urogynecology/
Reconstructive Pelvic Surgery
Department of Obstetrics and Gynecology
Rationale
●
Patients with conditions of pelvic
relaxation and urinary incontinence
present in a variety of ways.
● The physician should be familiar with the
types of pelvic relaxation and incontinence
and the approach to management of these
patients.
Objectives
The student will demonstrate knowledge of:

Predisposing factors for pelvic organ prolapse
and urinary incontinence

Anatomic changes, fascial defects and
neuromuscular pathophysiology

Signs and symptoms of pelvic organ prolapse

Physical exam

Treatment
International Continence Society
Definition of Urinary Incontinence
 Involuntary
urine loss that is severe
enough to constitute a social or
hygiene problem and that is
objectively demonstrable
Questions for Patients
Do you leak urine when you cough,
sneeze, laugh, or exercise?
 Do you leak on the way to the
bathroom?
 Do you know the locations of bathrooms
when you are shopping or travelling?
 Do you leak during intercourse?

Stress or Urge Incontinence?
EPIDEMIOLOGY

Estimates of prevalence vary
– Bias in sample surveys
– Patient under-reporting
– Differences in definitions, populations
studied and methods used

~ 13 million Americans are incontinent
– 10-35% of adults
ECONOMICS OF URINARY
INCONTINENCE

Direct health care costs
– > $15 billion/yr

Indirect health care costs
– Incontinence products
– Loss of work/productivity
Classifying Urinary
Incontinence
Stress
 Urge
 Mixed
 Overflow
 Other

– Functional
– Unconscious or Reflex
– Fistula
Tenets of Effective
Management

Assessment of
patient
 Risk factors and
reversible causes
 Treatment of
reversible conditions

Education
 Treatment options
– QOL improvement

Management plan
RISK FACTORS

Gender
 Immobility
 Environmental Barriers
 Altered Cognition &
Delirium
 Medications
 Smoking
 Collagen Disorders

Neurologic Disease
 Diabetes
 Stroke
 Menopause
 Childbirth
 Increased Abd Pressure
– Obesity
– Chronic Constipation
– Chronic Cough
– High Impact Physical Activity
PATIENT EVALUATION
 History
 Physical
Exam
 Laboratory Tests
 Urodynamic Testing
 Voiding Diary
History
HPI
 Mental Status Evaluation
 Functional Assessment
 Environmental Assessment
 Social Factors
 Voiding Diary

HPI

# Incontinent episodes
 Triggers
– Stress +/- Urge

Volume of urine loss
 Difficulty starting
stream (hesitancy)
 Sensation of
incomplete emptying
 Straining to empty








Number of pads/day
Frequency
Urgency
Nocturia
Enuresis
Dysuria
Hematuria
Post-void dribbling*
*Sign of what?
PMH
Parity
 Birth trauma
 Length of labor, especially 2nd stage
 Previous gynecologic and/or
incontinence surgery
 Back injury
 Medical History

– MS, DM, CVA, Parkinsons
Medications


Cholinergic
– Retention
– Bladder irritability

Alpha-adrenergic

Anti-cholinergic
Alpha-blocking
– sphincter tone
– Retention
b b
b
a
TCA’s are both anticholinergic and alpha adrenergic
Diet
 Caffeine
 Citrus Foods &
– Cranberry Juice!
 Spicy
Foods
 Alcohol
Drinks
Functional and
Environmental Assessment

Manual Dexterity
 Mobility
– Patient toilet unaided?
 Access
– Distance to toilet or bedside commode (BSC)

Chair/bed transfers
Voiding Diary
 Date
and Time
 Fluid consumption w/ type and
volume
 Voiding episodes w/ volume
 Leaking episodes
 Urgency
Physical Examination
General
 GU
 Neurologic
 Direct Observation of Urine Loss
 Post-Void Residual
 Q-Tip Test

Physical Examination:
Gynecologic








External Genitalia: excoriation, erythema
Vaginal Introitus and Mucosa: caliber, atrophy
Anterior Vagina: urethral diverticulum
Lateral Vaginal Sidewalls
Posterior Vagina
Uterine or Vaginal Cuff: procidentia, prolapse
Urethra: caruncle
Anus and Rectum: rectal prolapse, sphincter integrity
Physical Examination :
Neurologic

S2 - S4
– Sharp and dull touch

Perineum and buttocks
– Reflexes
Bulbocavernosus
 Anal Wink

Physical Examination:
Q-Tip Test






Assesses bladder neck mobility
Sterile technique
Anesthetic gel
+ 30o = UVJ hypermobility
SUI often has hypermobility
Hypermobility not necessarily SUI
- 20o
Urodynamics
Uroflowmetry
 Cystometrogram

– Leak Testing
Electromyography
 Micturition Study
 Urethral Pressure
Profile
 Videocystourethrography
 Cystoscopy

Urodynamics
Male or Female?
LABORATORY TESTING
 Urinalysis and Culture
– Bacterial mucosal irritation
– Unsuppresible detrusor activity
– Endotoxin inhibition of alpha-adrenergic
receptors in urethra
TREATMENT OPTIONS
Treating Reversible Conditions
 Behavioral Therapy
 Medications
 Devices
 Surgical

Reversible Conditions
UTI
 Atrophic urethritis/vaginitis
 Stool Impaction
 Dietary
 Medications
 Inadequate/Excess fluid intake

– How many mL/day?
Reversible Conditions
 Delirium
 Psychological
 Restricted
Mobility
Treatment of
Detrusor Overactivity
Dietary
 Toileting Habits

– Scheduled Toileting +/- BSC

Urge Strategies
– Pelvic Muscle Exercises
Biofeedback
 Electrical Stimulation

Treatment of
Detrusor Overactivity
Bladder has muscarinic receptors (M3)
 Medications

– Ditropan
Side Effects
– Detrol
-Dry mouth
– Sanctura
-Dry eyes
– Vesicare
-Constipation
– Enablex
-Cognitive dysfunction
– Imipramine
Surgical Treatment of
Detrusor Overactivity

Refractory cases
– InterStim Device
– Percutaneous Tibial Nerve Stim (PTNS)
– Augmentation Cystoplasty
Many associated complications
 Last resort procedure

Treatment of
Stress Incontinence

Burch Retropubic Urethropexy

Pubovaginal Sling
– Mesh or Fascial

Urethral Bulking
– Transurethral injection
Nonsurgical Treatment of
Stress Incontinence

PESSARIES
– Low morbidity
– Requires regular care
– Managed by patient

Fem-Soft
When to Refer?
Failed trial of conservative therapy
 Pronounced anatomic defect
 Persistent infection
 Desire or need for surgery
 Associated problems

SUMMARY

Investigation of the incontinent patient
– History
– Physical Exam
– Urinalysis and Culture
– +/- Urodynamic Testing
SUMMARY

Despite high prevalence and cost,
less than 50% of people with
urinary incontinence seek help!

So ASK your patients about it!
Definitions of Prolapse

ANTERIOR
– Anterior Wall Defect AKA Cystocele

POSTERIOR
– Posterior Wall Defect AKA Rectocele
– Small Bowel Herniation AKA Enterocele

LATERAL WALLS
– Paravaginal Defect

APICAL
– Uterine Prolapse
– Vaginal Vault Prolapse
ETIOLOGY

Childbirth
 Increased Intra-abd
Pressure

Neurologic Injury
 Genetic Predisposition
– Connective Tissue
Abnormalities
– Lifting
– Coughing
– Obesity
– Constipation/Straining

Estrogen Deficiency
Pelvic Organ Prolapse Repair
Symptoms of Prolapse
Pressure
 Bulging
 Vaginal irritation/Ulcers
 PAIN IS NOT A PRESENTING
SYMPTOM

Compartment-Specific
Prolapse Symptoms

ANTERIOR
– Stress urinary incontinence
– Incomplete bladder emptying
– Possible increased frequency of UTIs

POSTERIOR
– Incomplete stool evacuation
– Splinting to assist defecation
Consequence of Prolapse
Diagnosis:
POP-Q
THERAPY

Conservative Therapy
– Pelvic Floor Muscle Exercises
– Pessary

Surgical Therapy
Pelvic Organ Prolapse Repair

Anterior
Compartment
– Vesico-vaginal
supportive tissue
Pelvic Organ Prolapse Repair

Anterior
Colporrhaphy
– Reinforcement and
repair of vesicovaginal supportive
tissue
– Non-permanent
plication sutures
Pelvic Organ Prolapse Repair

Posterior
Compartment
– Rectovaginal septum
– Denonvillier’s
“fascia”
Pelvic Organ Prolapse Repair

Posterior
Colporrhaphy
– Reinforcement
and repair of
rectovaginal
septum
– Non-permanent
plication sutures
Pelvic Organ Prolapse Repair

Lateral
Compartments
– Arcus Tendinius
Fascia Pelvis
(“White line”)
Pelvic Organ Prolapse Repair

Lateral Compartments
– Reattachment of vaginal supportive tissue to
white line
Pelvic Organ Prolapse Repair

Apical
Compartment
– Uterosacral
ligaments to
 Uterus/cervix
 Vaginal cuff
Cervical Os
Pelvic Organ Prolapse Repair

Apical
Compartment
– Attachment of
uterosacral
ligaments to
vaginal cuff
Pelvic Organ Prolapse Repair

Apical
Compartment
– Attachment of
vaginal cuff to
anterior longitudinal
sacral ligament
using a graft
Sacrum
Vagina
Robotic Sacrocolpopexy

Apical Compartment
– Robotically-Assisted
Laparoscopy

da Vinci® surgical system
– Approved in 2005
• Hysterectomy
• Myomectomy
• Sacrocolpopexy
SUMMARY
Prolapse is associated with pressure,
but not pain
 Site-specific exam is aided by Q-tip
and half of speculum
 Site-specific approach to repair
 Treatment focused on symptom
improvement, not anatomical correction

Questions?